Cognitive Behavioral Interventions for PTSD

This episode was pre recorded as part of a live continuing education webinar on demand. CEUs are still available for this presentation through all CEUs. Register@allceus.com Counselortoolbox you I'd like to welcome everybody today's presentation on cognitive behavioral interventions for post traumatic stress disorder. I am Dr. Donnelly Snipes. Tonight we're going to review the symptoms of post traumatic stress disorder real quick because most of you are probably already familiar. And we're going to explore interventions in the following acceptance and behavioral acceptance and commitment therapy, dialectical behavior therapy, cognitive processing therapy, and a few other cognitive behavioral techniques. Techniques. We're also going to look at behavioral techniques including exercise, sleep, nutrition and relaxation because cognitive behavioral is, guess what, a combination of both. So we want to look at how this might happen. But first we're going to start after we review the symptoms for ptsd, we're going to look at why cognitive behavioral therapy might be helpful and then we'll move into our interventions. PTSD symptoms in the DSM 5 they added a fourth category of symptoms. And so it's a little bit different than it was in the DSM iv, but not too much. You have the category for re experiencing the traumatic event or intrusive symptoms that can be memories, flashbacks, nightmares, feelings of distress when reminded, or intense physical reactions to reminders. PTSD symptoms of avoidance and emotional numbing is another category where people have to have symptoms, avoiding reminders of the trauma, inability to remember important aspects of the trauma. That one really frustrates a lot of people who have PTSD because they really want to remember what happened. They want it to make sense. Loss of interest in activities and life in general, feeling detached from others or emotionally numb, and a sense of a limited future. The third category is symptoms of increased arousal or hypervigilance, difficulty falling or staying asleep, irritability, outbursts of anger, difficulty concentrating, hypervigilance, constantly being on sort of red alert and feeling jumpy and easily startled. And the fourth category is negative alterations in cognitions and mood, characterized by an inability to recall key features of the trauma, overly negative thoughts or assumptions about oneself in the world, exaggerated blame of oneself for whatever happened or blaming others for whatever happened, negative affect, decreased interest in activities and feelings of isolation. Like I said, most of you are probably super familiar with all those, but for the sake of, you know, being well rounded, I wanted to go over those symptoms really quick. So let's talk about what happens in trauma though, because in order to understand how we're going to treat it, we need to understand kind of what's happening and how what we're doing is supposed to be affecting the person. So when people are exposed to stressors, the HPA axis, I call it the threat response system, and the amygdala are activated and they go, okay, there's a threat going on. We need to release cortisol, which we all know is the stress hormone, which triggers the fight or flight response. So we have excitation activation. The person is ready to fight or flee. Their heart rate's faster, they're breathing faster, which is great in the short term because that helps us survive. That is the awesome thing about the HPA axis. It helps us survive. Sustained exposure to cortisol, however, has an adverse effect and impact on the hippocampus, which is part of our brain that's responsible for learning and memory. It results in reduction of neurons and the dendrites don't branch as much, so we don't have as much connectivity going on in there. And you'll learn in a little while that reduced volume of the hippocampus is also a key feature in ptsd. Well, what happens if memory and learning? You know, we're talking about cognitive behavioral therapy here where we're helping people cognitively process. Well, in order to cognitively process what's going on and address how they feel and what they're thinking. You know, memory and learning is kind of involved in that. So if during trauma that area is kind of sucker punched and it starts to lose volume and lose connectivity, we can see where there might be problems. Doesn't mean that it's permanent. You know, we can help people develop reconnections. Think about people who have strokes or traumatic brain injury. Our brains are really awesome because they learn how to do workarounds. It's like, okay, we got a roadblock here where something happened. Let's branch and do something a little bit differently. A blunted response to cortisol stimulation indicates pituitary receptors in the HPA axis have been down regulated in patients with ptsd. So what that means is when cortisol is sent out for the fight or flight response, people with PTSD at a certain point may not react with the same level of excitation as other people because their body has down regulated. It said, you know what, we can't, we, the body cannot deal with this much stress and this much excitation for this long. We need to conserve energy for when there is, you know, super duper threat out there. So we're not going to get quite as fired up now on the downside of that is when they do get triggered, when there is a cortisol response, it tends to be a dysregulation. So the person gets really upset. They go from, you know, not being too upset to terrified. Hypocortisolism and PTSD occurs due to increased negative feedback sensitivity of the HPA axis. Again, it's being down regulated, so not as much cortisol's being sent out. The brain goes, you know what? I can't deal with all these stressors right now. I'm done. I need to conserve energy because I can't win this fight, whatever this fight is right now. Early adverse experiences, including prenatal stress and stress throughout childhood, has a profound and long lasting effect on the development of neurobiological symptoms, which may program subsequent stress reactivity and vulnerability to develop ptsd. What we've learned so far is people who are experiencing stress activate their HPA axis in the face of chronic stress and chronic activation of that HPA axis. Cortisol levels go down the HPA axis. There's primary and secondary hypocortisolism, but the HPA axis basically down regulates. What you're going to learn in a few minutes is that people who have hypocortisolism when they're exposed to a trauma. So people who've had chronic stress or trauma in their past who are exposed to a new trauma are at a higher risk for the development of PTSD because of that hypocortisolism. So one of the takeaways here is really important that we intervene early, early intervention prevent, to help people not experience chronic stress. So if they're faced with a traumatic event of any sort, it can be a car accident, it could be a death of a family member, whatever. But if they're in a situation where they're faced with a trauma that they're not experiencing hypocortisolism already because we know that that's a risk factor. Hypocortisolism plus trauma can, can lead to ptsd. So anyway, the hippocampus, which as I said earlier, is involved in learning and memory, and the prefrontal cortex, which is where we do our impulse control and higher order thought, mediate the HPA axis. So our memories in our hippocampus can say, you know what, I remember this, it's really not that big of a deal. Chill out. The prefrontal cortex, on the other hand, can look at it and objectively assess the situation and go, you know what, we're good, right? Now we don't need to fight or flee. You know, we can table that impulse for right now, but review. Reduced volume of the hippocampus is a cardinal feature of ptsd. So again, if that hippocampus has shrunk, basically, then we may not have learned as much or we may not have as much access to those memories. You know I said the dendritic branching reduces, so we may not have access to some of those memories in there. Interestingly, hypocortisolism is thought to be an autoimmune response. You know, I said the body down regulates in response to chronic stress. Another hypothesis, not necessarily contradictory, is that it's an autoimmune response to stress. Physical and psychological stress has been implicated in the development of autoimmune diseases. So hypocortisolism is thought that it may occur after a prolonged period of hyperactivity of that HPA axis due to chronic stress. Again, we need to get in there and help people figure out what's causing your stress so you are not chronically stressed. That way you have the reserves to deal with trauma when unfortunately, it inevitably happens. The phenomenon of hypocortisolism has been reported not only for people with PTSD, but also for healthy individuals living under conditions of chronic stress, be it emotional or physical. You don't have to have PTSD to have hypocortisolism, but if you've got it, you're at a higher risk. Glucocorticoids or cortisol interferes with the retrieval of traumatic memories, an effect that may independently prevent or reduce symptoms of ptsd. Which makes sense. If you don't have enough cortisol and you're exposed to a trauma, then you're more likely to solidify those memories and experience ptsd. If you've got enough cortisol, then, interestingly, the brain says, you know what? You don't need to remember that right now for all intents and purposes during this stress situation, and it actually prevents the formation of some of those traumatic memories. Hypocortisolism might be a risk factor for maladaptive stress responses and predispose people to future PTSD or stress related bodily disorders, including any of those autoimmune diseases that are out there. And there's about 20 of them. Another interesting little fact, simulation of a normal circadian rhythm or cortisol rhythm using externally introduced hydrocortisone is effective in the treatment of some symptoms of ptsd. Now, this is not to say go out and start encouraging people to use steroids or something to increase their cortisone. No, no, no, no, no. What is interesting is that when the circadian rhythms are in balance, your normal cortisol goes up first thing in the morning. That's why you wake up and get out of bed. Theoretically. And it gradually decreases during the day, and it's at its lowest point when it's time to go to bed. With people that have hypocortisolism, that cortisol may never go up. So it's hard for them to get out of bed. They may feel kind of depressed, withdrawn, negative. You know, one of those symptoms of ptsd, core neurochemical features of ptsd. And you all know that I am a huge fan of neurochemistry. Regulation of dopamine, norepinephrine, serotonin and opioid neurotransmitters is all dysregulated. Each of those neurotransmitters or receptors for those neurotransmitters is found in brain circuits that regulate and integrate stress and fear responses. Well, hello. There's some interesting stuff there. Now, one thing I do want to point out is that dopamine, most people think about dopamine as our pleasure chemical, and that's kind of a misnomer. Dopamine is actually our motivation chemical. It's our go after that and get it again chemical. Our endogenous opioids are the ones that are more the pleasure chemicals. So when dopamine goes up, opioids also tend to go up. So dopamine is your seek neurochemical. It's the one that's going to give you the drive to do things, which is another one of the reasons when we see people who take atypical antipsychotics, they tend to be sleepy and not have as much motivation if their dopamine system is inadequate. A cardinal feature of patients with PTSD is sustained hyperactivity of the autonomic nervous system, as evidenced by elevations in heart rate, blood pressure, and other psychophysiological measures. We all know what panic looks like. Patients with PTSD exhibit increased heart rate, blood pressure and norepinephrine responses. So stress response, increased HPA axis in response to traumatic reminders. You don't have to be in that situation. Again, anything that reminds the person of the trauma can trigger to a greater or lesser degree, their HPA axis, which again tells you that you've got somebody with PTSD who's going to have a more sustained HPA axis activation as they're exposed to various triggers. And it can be anything from commercials on TV to smells, to sites, to places, to people, whatever. And this is where cognitive behavioral comes in. We need to help them start identifying some of those traumatic reminders and figuring out better ways to cope with them so it doesn't trigger that HPA axis response. Chronic exposure to stressors induces upregulation of 5 HT2, which is one of the serotonin receptors, and down regulation of 5ht1a. Now, the takeaway from this, if you don't want to get into all the neurochemical stuff, 5ht1a is the one that is usually implicated or talked about in terms of depression and anxiety. And that's where your SSRIs generally target is that 5ht1a receptor. The 5ht2 axis is actually more responsible for anxiety, appetite, cardiovascular function, GI motility, alertness, and vasoconstriction. Well, all of those in HPA axis activation, when there is more of the serotonin, all of those tend to be affected. People get more anxious, their heart goes faster, their GI motility increases, they become more alert, hypervigilant. So there's a lot of stuff that we see that makes sense. 5ht transmission may contribute to symptoms of PTSD, including hypervigilance, increased startle impulsivity, and intrusive memory, because that 5ht2 is upregulated. And remember 5ht, any of those are your serotonin receptors. So increased levels of certain serotonin receptors can be responsible for a lot of the symptoms we see in ptsd. To kind of summarize, hypocortisolism is a key feature in ptsd. It probably results from an autoimmune reaction. Autoimmune reactions are triggered or worsened by stress. So people with PTSD may have excess dopamine, norepinephrine, and insufficient serotonin at the H1 receptor. So we want to increase that 5 HT1A receptor serotonin. So cognitive behavioral treatment goals would be aimed at reducing physical and psychological stress, including improving nutrition. So the body has the building blocks to make the neurotransmitters it needs. Reducing stimulant exposure, improving sleep, and addressing cognitive issues that maintain the stress response. Okay, so now we're getting into the good stuff. There are behavioral interventions. So sleep, when you are sleep deprived, your body perceives that as a stressor. It says, I'm tired. That means I'm not as alert as I need to be, and so I need cortisol to help keep me awake. And alert if I can't go to sleep. So when we are overtired, our HPA axis or our cortisol levels tend to be higher. That's not something we want. People with PTSD tend to have very poor sleep, insomnia, you know, or difficulty sleeping. One of the key interventions they found is to work with people to help them improve their sleep and that'll help reduce some of their HPA axis reactivity. Think about when you're sleep deprived. Does the world seem a little bit more difficult to deal with? I know for me it does. I'm just like, really? I can't take one more thing. Maybe that's just me. But there are a lot of people who experience stressors more intensely when they are sleep deprived. Think about if you've ever had children, you know, when they first come from, come home from the hospital and for the first three, six months they're not sleeping through the night, which means you're not sleeping through the night. And you know, it gets a little bit challenging sometimes. Sleep is really important. Have people examine their sleep hygiene. Create a sleep routine. On our YouTube channel, there are a couple of videos that go in depth on helping people improve their sleep. Nutrition is another one. And again on the YouTube channel there are, or on the podcast, there are other episodes that cover nutrition for mental health. But suffice it to say that your body, in order to make serotonin, norepinephrine, dopamine, gaba, all of those neurotransmitters, it has to have proteins. But in order to make those proteins into the neurotransmitters, it also has to have a certain amount of various vitamins and minerals, from calcium and folate to iron and magnesium and yada yada. A good balanced diet is essential to make sure that people are actually able to create the neurotransmitters they need to feel balanced. We need to help them stay hydrated for cellular function. If you think about how everything communicates in our brain and our body, it communicates through chemical signals. And these chemical signals require fluid. You know, that's why dehydration is so challenging. We need to make sure that people stay hydrated. That's not going to be the be all, end all, but it's another one of those goals that we can set for people. Help them exercise for oxygenation and to increase in their serotonin. They've done study after study after study that has shown that exercise can help people reduce muscular stress. You know, we store stress in our back and Everything else, when we exercise, it tends to help us loosen up, and it increases oxygenation throughout our body, which is another good thing for mood and everything else. And they've shown that exercise actually does increase serotonin levels. So why not? Now, exercise does not have to be going to the gym. It can be playing with your dog. It can be closing the blind so nobody can see you and dance like nobody's looking. Whatever it is that moves your body is exercise. And it doesn't have to be 30 solid minutes. You know, that may be way too much for some of our clients. If they can do a commercial break while they're watching tv, maybe they can do crunches or whatever their doctor approves. That is exercise. Anything to get their body moving. And eventually, we'd like to see them get to the point of getting at least 200 minutes of moderate exercise per week, not per day, per week. We want to help them eliminate unnecessary stressors. And that's a behavioral thing. If you don't like driving in traffic, if it stresses you out, well, then how can you get around that? Can you take the train into work? Can you carpool into work? Can you leave earlier so you're not driving through traffic? Can you work from home? Think about different ways, and, you know, have clients list all of their stressors. No stressors too small. Let's just get them all out here and lay them all out. You can do it on index cards. You can do it on a whiteboard. I prefer the whiteboard. So we don't kill trees, but whatever. And let's figure out everything that stresses you out, and then let's start marking off the ones that you can just work around or get rid of. Then what's left? Let's figure out how to mitigate those. Encourage people to do things they enjoy, to relax. Life is not just about work and sleep. Sleep is important, and so is work. But we also need to have time to relax. One of the activities I do with my group sometimes is I'll bring in a box, and I'll have representations of different stressors. I'll have bills in there and a little toy car that's been banged up and various other stressors, and I'll have all those in the box. And we talk about reducing stress and eliminating stressors, and so we talk about how to eliminate each one. I pull them out of the box, and then when we're finished, I show them the box, and I'm like, well, what else is in here? There's nothing you have to add in the positive, because you want to fill yourself up with positive. If you just eliminate the negative, the positive generally doesn't magically spring up. We want to help them figure out what makes them happy and encourage them to do something for 30 minutes a day. I know that's a big, big jump for a lot of people. 30 minutes a day that they enjoy and it helps them relax and they should laugh often. One of the quote prescriptions I give to a lot of my clients is I want you to listen to some sort of comedian or do something that makes you laugh for 10 minutes a day. Laughing for 10 minutes is a lot. But you know, you can find 10 minute videos or whatever on TV that are on YouTube that are really humorous. And a good laugh can increase your immune system as well as reduce cortisol levels. That's better than any drug can do in many ways. Another behavioral technique is environmental grounding. Encourage them to look into feng shui or just look around their room, their office, their car, their home, and eliminate unnecessary stress when they're sleeping. You know, they don't want to have a window behind their head if possible. They want to be able to see all entrances and exits to the room. That's just a feng shui principle. You don't want to be able to have somebody sneak up on you because when there's a possibility of that, then we tend to have this low level of anticipation. Encourage people to look around so they have an environment where they feel like they're not going to be trapped. They feel like they're free, they're safe, and they feel like they're free from getting startled. And that can be by somebody walking up on them or even by loud noises. We have dogs and when the, when the UPS man comes, it gets really, really loud. If somebody has aversion to loud noises like banging cabinets or barking dogs, whatever they may consider at certain times of day when they're trying to relax, having noise canceling headphones on and that can help blunt that startle response so they're not jumping out of their skin. Keep a light with a red bulb or yellow if red is a trigger. Some people were when they experienced their trauma, there was some sort of a red light. So if red is a trigger, then don't go there. But yellow, just not blue, because blue messes up your circadian rhythms. Keep a light with a red light bulb by the bed so when you wake up you can turn that on and get regrounded. The unit that I ran for veterans, we used to have a lot of veterans that had night terrors. And that was one of the things that we did. So when they woke up, they could get reoriented really quickly, but they wouldn't completely destroy their sleep cycle and they wouldn't wake up their entire, entire unit. If a night light is needed. Some people do need night lights. And this can be for older people or people with, you know, really bad night terrors, whatever. Ensure that it's no more than 5 watts and is yellow or red to minimize disruption to circadian rhythms. So if you have to have a night light on consistently, don't use a blue light or a white light because the brain registers that as time to wake up. For some people, it's helpful depending on what the trauma was. For some people, it's helpful to get a dog if they were victimized by another person or, you know, after, if they were in combat and they were always on alert for other people that might want to hurt them. Sometimes a dog can be a good tool because people can go to sleep and they know that the dog is going to wake up and bark if it senses anything is a little bit amiss. And people tend to be much calmer when they have that, you know, living, breathing burglar alarm, so to speak. Now onto the cognitive stuff. Understanding is the first place where I start with a lot of my clients. When people see how their symptoms make sense, it's easier to deal with them. Avoidance symptoms. After a trauma, you don't want to go back to that again. If you were in a house fire, you certainly don't want to think about something that is going to set your house on fire again that's going to trigger those memories. Your brain doesn't want to remember that, and your body and your brain doesn't ever want to be in that situation again where it might be exposed to a house fire. So avoidance makes sense. That's dangerous. Don't go there. Hyper vigilance makes sense. It's your body going, okay, you were resting on your laurels the last time and it kind of bit you in the butt and look what happened. You were exposed to this trauma, whatever it was, and now you need to be more alert. And the combat trauma is a little bit more different or a little bit different because, you know, they are constantly hyper vigilant, waiting for somebody to come attack them. But hyper vigilance makes sense. It's your brain's way of going, hey, I want to live, so I need to stay extra alert so I don't get caught unawares, intrusion, flashbacks, make sense when trauma happens, you know, when things happen. Let's start that. When things happen, you know, you drive across town and, you know, get to your house and you park your car, and you see a package that's sitting there. Whatever. All of those things make sense. Oh, the postman brought a package. Let me get it. Let me open it. You integrate it. It's like, what happened was supposed to happen, and you file it away in your memories. Things make sense. Trauma does not make sense. Trauma does not make sense. So a lot of times people have difficulty integrating that. It's like, what do I do with this? I thought the world was safe, but not now. Or it seems like everything's dangerous, but then you're telling me I'm safe. I don't know how to integrate my experiences with current and past reality. So they're stuck with this thing in their amygdala going, okay, there's this traumatic reaction, and we really don't want to go back there again. But I don't know what file to put it in, what memory file. So it's hanging out there kind of like a loose end. And negativity. Well, you know, think about it. After something bad happens, and you don't know exactly how to deal with it, so you want to protect yourself instead of saying, okay, that was a bad situation. Everything else is fine. We tend to overgeneralize to a certain extent, and we may become more suspicious of other people. We may become more negative in our interpretations, looking for ulterior motives, it makes sense. We want to survive. Once people realize that and they start saying, okay, you know, I thought I was just, you know, weird or something. No, that is your body. Now. What we can do is figure out what's making these things happen and figure out ways to deal with it. Many people who get. Who experience trauma have difficulty integrating that trauma into their schema. So they get stuck in that fear or the amygdala or in the back of their mind going, I told you so. It was dangerous. You know, got to pay attention to me next time loop. So we really want to quiet that amygdala down. He's a nervous Nelly. Or she. I don't know. One of the first steps a lot of clients feel like they need to go through. And, you know, when I work with clients with ptsd, I don't necessarily start with telling your story. I like to make sure that they have a safety plan and. And that they are as energized and recharged as they can be. They've prevented as many vulnerabilities. They've got as much cortisol as possible before they start telling their story so it doesn't trigger a crisis. Not everybody's willing to wait. However you end up doing it with your clients is how you end up doing it. But when they tell their story, it's very difficult for a lot of clients to relive that experience while sitting there looking someone else in the eye and sitting still. You know, think about how uncomfortable it is to tell somebody about the worst and sometimes the most humiliating moment of your life while sitting there looking them in their. In their face and they're just nodding and you're like, I really don't want to be telling you this. So there are ways to make it a little bit more comfortable. One thing can be to ensure the client has something to focus on. Sometimes bouncing a ball against tennis ball against the wall can be something. They're focused on that tennis ball and they're grabbing it and they're talking to you. That's fine. You know, if you've got a racquetball court outside or you can go outside and there's a brick wall they can throw a tennis ball against, that can be a good place to be. So they are focusing on something outside of themselves. You don't have that. You can pass a ball back and forth. You can bounce a basketball if you've got a place to do that. Something where they have to be using their body. Some people prefer to swing and look at an object like a wind chime. I know a couple of therapists who have swings in their office. There are those kind of like egg shaped chairs that you can sit on and they're suspended from the ceiling. People can swing sort of rhythmically, which is comforting for some people. And they can watch a wind chime. They're not having to look at the therapist. And some prefer doing something they enjoy like cooking or exercising. Now, obviously confidentiality is huge here, so you've got to figure out where you can go whether you're doing an in home session or if you have a that you can go where people can talk freely and no one's going to overhear them. But those are all techniques that you can use while the client is telling their story to help keep them moving forward. Make sure the client feels safe and reassure them regularly that they're safe when you're talking to them. Continually use past tense words and reaffirm for the client that they are safe in the process present, such as if they're Telling you about something that happened when they were a child, you can talk about how well that was really overwhelming for you at that age. Or if you're working with a veteran, you can talk about when you were deployed, you were constantly on edge and talking about things in the past, making sure that they recognize and can start differentiating. The past is back there. That traumatic event, that awful thing that's right here on the timeline. And we're here now. It doesn't mean you're not upset now. However, you don't have to bring all of that with you. EMDR does a lot more with that. It's a lot more in depth. But if you're not EMDR trained and you're struggling to help clients tell their story, those are some techniques you can use to help them start articulating. Cognitive behavioral therapy for trauma is another technique that is used mainly with children to help them deal with traumatic experiences. And you can find trainings on that. I've got a couple of videos on that on the YouTube channel as well as podcast episodes. But there are techniques that can be used and that involve helping people tell their story then and now. Help clients identify how they are different or less vulnerable now than they were then. If you were abused when you were a child, that was horrible and you were stuck and you were helpless because you couldn't fend for yourself. Now what strengths do you have? What safety do you have? Help clients identify the ways the trauma changed how they feel about others, including strangers, you know, people they've never seen before. Does it make them more suspicious or wary of strangers? People in their own family and even their kids? Some people who are victimized as children may, when their children get to be about that same age, may have a resurgence of their PTSD symptoms because they start seeing the trauma happening to their children. Help them identify how the trauma affects how they feel about themselves. Does it make them feel broken, worthless, powerless or not? And how did it change their outlook on life? Once they articulate these things, then you can start addressing them one at a time. Help them address any cognitive distortions by finding the exception and getting the facts for just about any cognitive distortions. Distortion, one or the other of these techniques usually works. Evaluate people's thinking for mind reading. For example, in trauma, somebody might say, I can tell that person is dangerous or wants to hurt me. So you know, I'm reading their mind. I'm knowing that they are thinking about hurting me. Well, no, you're not. You may have your spidey senses may be going off. But you don't know that that person wants to hurt you. So look for the facts in that situation. What are the facts that are telling you that you're in danger? All or nothing thinking or polarized thinking? Somebody who's been traumatized may say, I will never feel safe again. Well, it's going to be hard to feel safe in all situations. But let's think about the exceptions. When in the past 24 hours. Or you can even start with, do you feel safe now? And if they say yes, you can say, all right, when else in the past 24 hours have you felt safe? So they can start identifying situations in which they do feel safe. And hopefully we can expand those situations. We can't promise them that bad things won't ever happen again, because bad things happen. But we can help them recognize that the majority of the time they are safe. Those are the facts. And then they can start addressing factual versus emotional reasoning. In emotional reasoning, we think that something is what it is because we feel a certain way. So if we feel scared, then we figure out a way to convince ourselves why this is scary. You know, if I'm getting ready to go do a presentation to 200 people and I feel anxious, then I might start trying to think about all the reasons why this is terrifying. And that's emotional reasoning. Factual reasoning would be, you know, I'm getting ready to go talk to 200 people. Let's think about in the. In facts. How many times have I done this before? Have I ever, you know, passed out on stage or, you know, whatever I'm worried about? No. So helping them differentiate fact from feeling catastrophizing. My life is over. I'm ruined. There's a lot of that foreshortened future sort of thinking that happens after trauma. Again, have people look at the facts of the situation. Is your life over? You know, is there nothing meaningful left in your life? And you have to be careful how you phrase these questions because that's kind of rude to say. So you're saying there's nothing meaningful left, but you want to get to that generally by helping them see that, you know, there are still some things in their life that are meaningful. Overgeneralization, again, have them look for exceptions. If they see that, you know, maybe they were attacked by a person that looked a certain way. Now every person that is of that same gender, ethnicity, whatever they see, they think is dangerous. We want to help them start looking for exceptions to that rule. Shoulds. A lot of times people blame themselves. I should have known better. Or I should have turned off the oven, or I should have done this, that or the other. We can't change what happened in the past, so we want to help people look for the facts. A lot of times, people did the best that they could with the tools that they had at that time. Some people, when they are exposed to trauma, freeze. They don't fight, they don't flee. So they start blaming themselves for what happened. I should have run, I should have screamed. But you couldn't. You know, it's just one of those things that you did what you could do at the time. Now what do we do to move forward? And then the recency or availability heuristic is when the person judges life forever and ever based on what recently happened. So if they were attacked in a parking garage or they were in a high rise when it caught fire, whatever the trauma was, they may start thinking parking garages are not safe. Never, ever. Well, that's just because that recent experience they had is so prominent in their mind. They've walked through parking garages 500 times before in their life, and nothing bad has happened. So we want to help them look at the facts and really separate high probability from low probability. Nancy points out that there is another technique where you can ask people if they feel 100% safe at this moment. And if they don't, then you can talk about what would help you feel 100% safe and encourage them to start working towards that and developing areas and times where they feel 100% safe and then explain expanding that. It's, you know, like Nancy says, it's hard for them to do a lot of times, but it is possible. And once they start finding these places where they feel 100% safe, they can breathe. Constructive self talk help clients develop survivor scripts. Use button pins, those little pins that you put on backpacks. I love using those in group activities. And have people write constructive self talk those pins. So if they frequently say things like, I should have run, or I should have fill in the blank, whatever it is, have them find a constructive response. I did the best that I could, or whatever works for them. And create a button pin out of that. And then they can have a whole sash or wall or bulletin board of button pins. They can also do a collage or we've done before in my trauma groups, a ribbon tree. And it looks a lot like a Christmas tree, but they create ribbons, you know, like the little ribbons we wear around for breast cancer awareness or any of those other things. And they write the constructive self talk on Those ribbons and we hang them from the tree so the tree is filled with constructive self statement. Speaking of trees, you can use the tree metaphor. I like the tree metaphor, but I'm kind of one of those tree hugger people. Have clients start out by describing the tree. What do you see? Describe this tree to me. Then have them describe how the tree might represent their life. And you know, you can spend quite a bit of time on this in group. Ultimately, what we want to get to is trees are beautiful, vibrant and full of life. Their sturdiness provides shelter for vulnerable creatures. So because they are strong, because of everything they've gone through, they're able to protect others. All trees are impacted by their environment. You know, if it's too salty, it may make the leaves wither a little bit. If it's, you know, they're not getting enough water. So it's important for them to be in a healthy environment so they can grow. All trees have unique shapes based on what happened to them and what was pruned or not. As things happen, you know, this tree has a split down the middle. And it could be that there was a stone that was there that kept it so it had to grow up and around or I don't know, it could have just grown that way. But every tree has its unique shape based on its own experiences. If it was droughty, if it was rainy, if it, you know, our donkeys will regularly eat the bark off part of our tree, so then, you know, part of it'll die off. And that shapes that tree. That happens to all of us. We are shaped by all of our experiences. Trees are rooted in the dirt, which is made up of remnants of the past. So every year the tree sheds its leaves or the pine needles fall down as they die and they decay and they make the soil that eventually feeds the tree. So what we create, what we're exposed to, we also use to feed ourselves. So we want to expose ourselves to positive things and feed ourselves with positive things. Another activity you can do is logging. I'm a behaviorist at heart. Keep a log of flashbacks or startle responses or both. When they occurred, what triggered them, if known their intensity. On a scale from 1 to 5, how well the person had slept the prior night, the amount of caffeine, alcohol or nicotine in the preceding hours. Because stimulants tend to trigger the startle response and keep the HPA axis revved up and prior stressors that day. Again, if they were already, if their HPA axis was already revved up, if they Were already worn down from being under chronic stress, then they may be more vulnerable to flashbacks or startle responses. Use these logs to help people chart the reduction in frequency or intensity of the intrusive or hypervigilant symptoms. If they feel like they're not getting any better. You know, let's look. Let's see if maybe you're still having flashbacks twice a day, but the intensity has gone from a five down to a two. Okay, you know, you're still having them, and we'll work on that, but the intensity is decreased. We want to help them see those small steps in the right direction. And the logs can also help them identify triggers or vulnerabilities, such as too many stimulants or not enough sleep. And it starts helping them see how their body and taking care of their body is so important in helping address the PTSD symptoms. ABCDEF is one of your basic cognitive behavioral strategies. It's effective for anxiety and negativity. I don't ever use this for intrusion because intrusion is not something people. I don't want them to think that they bring it on themselves. I want them to use this in order to address things that they do have cognitive control over, and they can choose not to think that. So activating event. What happened? You know, somebody you saw. You saw a fire truck drive by, and it reminded you of when your house caught on fire. Okay, so you start having anxiety going, oh, I hope that's not going to my house now. And. And getting all worked up about it. So you get upset. Those are the consequences. Encouraging people to look at the beliefs about this activating event, the beliefs about that fire truck that went by that triggered their anxiety and dispute them for their rationality. How rational is it to assume that it is going to your house or for people whose houses got struck by lightning? You know, when a thunderstorm comes along and they start to get panicky, you know, encouraging them to identify that the thunderstorm is the activating event, the consequences, they're getting upset. What are their beliefs? Well, one of them is probably, we're going to get hit by lightning again. So then addressing whether that is probable not and figuring out how to address it, and then e is evaluating the most productive outcome. So let's stick with the lightning for right now. Is worrying about it worth my energy? No. You can't control whether lightning is going to strike you or not. You know, you can be inside and you can be in a safe place, but after that, you can't control whether it's going to Hit your roof, unfortunately. So how can I best use my energy to deal with or let go of the situation? What can I do to help myself get through and improve the next few moments while we're in the storm? Systematic desensitization, on the other hand, is helpful for intrusion. Have them identify a feared situation, such as being at home alone. Maybe they were home alone when they were attacked, so being at home alone is terrifying. Have them identify. Think about it. You know, being at home alone during the day. First, imagine it. Have them rate their anxiety on a scale from 1 to 5, and then use deep breathing and grounding and mindfulness skills until they can imagine it and not feel bothered. So the deep breathing in for four, out for four triggers the rest and relax response. Grounding skills can include telling themselves, you know, where they're at and that they're safe, and even looking around and identifying five things that they see, four things that they hear, three things that they smell, two things that they can touch, and one thing they can taste. That helps them stay grounded in the present moment instead of going back wherever there was. But encourage them to practice this, and it's not going to happen the first time. Encourage them to practice this until they can imagine being at home alone during the day, and it doesn't really bother them. They're like, you know what? I think I can do that. Once they can, then you ramp it up a notch. So the next step may be being at home alone for 10 minutes after everyone leaves in the morning. So people just left. So you know that, you know, there's lots of activity going on. You know, you were safe 10 minutes ago. Can you feel safe for 10 minutes? Once they get to the point where they can imagine it and not feel anxious, take it up another step, such as stay home alone during the day for 30 minutes when you know a neighbor or that you're. That is your friend home. So, you know, you could call that person and they would come right over. Get to the point where the person can do that without getting anxious. Then staying home alone during the day for an hour, and then staying home alone until it gets good and dark. You know, it gets dusky, and then it starts to get dark. I remember when I was a little kid, as soon as it started to get dusky, I was like, okay, when's mom getting home? Then staying home alone after dark. And then the biggie for a lot of people is going to sleep when they're home alone. And there may be other steps in between for different people, but basically it's like a ladder. And you want to help them gradually get to the point where they can approach their feared situation and not feel anxious. They start out by being able to imagine it. Then they work up to being able to do it without experiencing high levels of anxiety. Dialectical behavior therapy is awesome for anxiety, negativity, withdrawal and avoidance, and even to a certain extent, intrusion. You want to prevent vulnerabilities, which means help the person figure out what they need to do. So they're on their A game so they're as rested and they're cortisol's all in balance and everything as best as they can. Good sleep, good nutrition, good social support, all that stuff. Encourage them to practice mindfulness to prevent vulnerabilities. So they're aware of how they feel in the moment and they notice when they're starting to get tired or they notice when they're starting to get stressed. So they can address it early and use mindfulness to prevent or mitigate triggers. When they notice something's going on, then they can address it earlier. Or if they're at a friend's house or even at home watching TV and a commercial comes on. Commercials are big triggers for me. And a commercial comes on or a television show has a scene in it that's triggering, they can ground themselves and they remember those triggers or they remember those techniques such as 5, 4, 3, 2, 1. Help them understand that distress is inevitable. Because if people are trying to recover from trauma and they think, well, I need to make it all go away, they're going to be sorely disappointed. But they can develop distress tolerance skills, including urge, surfing, and the acronyms accept and improve. And those are things that you can look up online or in the dialectical behavior therapy episode. But ACCEPT stands for activities, comparisons, contributing emotions, pushing away, and sensations in order to help people get through that place where they're feeling the adrenaline rush until they can get into their wise mind and decide what is the best next step. Improve stands for imagery, meaning prayer, relaxation, one thing at a time, take a mental vacation and encouragement. Self encouragement or encouragement from others, it doesn't matter. Let's get some encouragement. And DBT also encourages people to embrace the dialectics, recognizing that every situation has good and bad aspects. So if they can embrace the bad with the good, then it's going to be a much easier road than trying to find situations where there's only good and there's no bad. It just really doesn't happen. Acceptance and commitment therapy is another great tool that can be effective for anxiety Negativity, withdrawal and intrusion. In act, people learn to accept what is in the moment. It is what it is. And in dbt, they call it radical acceptance. In act, people learn how to diffuse from their thoughts so they're not connected to it anymore. Instead of saying, I am terrified or I am in danger, that's fusion with your thoughts saying I am having the thought that I'm terrified or I'm having the thought that I'm in danger. Because all of us who are getting older know that thoughts can come and go even before you make it into the room to remember what you were going in there for. But thoughts are different than who we are. ACT encourages people to define their goals and values so they figure out what's important to them. What do I want to focus on, what things do I have going for me and choose purposeful action, choose to do the next thing that's going to help them get closer to their goals. And finally, he talks about living in the and and I love this concept, living in the and understanding that you can have a rich and meaningful life and experience fear sometimes and experience distress sometimes. I can stay home by myself and feel anxious. You know, I can do both of those and I can get through it. Cognitive processing therapy is effective for anxiety, negativity and withdrawal. You want to help people evaluate situations and their beliefs. Looking at the facts for and against their belief, identifying whether their belief is based in facts, in emotions like we talked about earlier, or just in habit. You know, they've always thought this way, so they're continuing to think that way. You know, that may not be the most accurate way to go. Are they using cognitive distortions, all or nothing thinking, personalization, mind reading? We talked about those. If so, address that. Are you focusing on only one aspect of the event or confusing high and low probability, like the house getting struck by lightning a second time? Are you focusing on irrelevant factors? You know, all of those are yes or no questions. Is this thought getting you closer to what you want? And if not, what is a better thought that helps you get closer to what you want? What are the advantages or disadvantages to thinking this way? And what difference will this make in a month or a year? Oops. Trauma impacts the person. Biopsychosocially. Behavioral interventions can help them prevent and address avoidance and hypervigilance, which is great, you know, we really want to help them be as physically strong and well armed as possible and have that HPA axis in sync, have their circadian rhythms in sync so their cortisol is in sync so their body is ready to deal with life as life comes. That's the first step. And then the cognitive interventions can help them understand the function of their symptoms to choose effective ways of dealing with them. The function is to help me survive. Okay, well, first I need to figure out in the present, am I really in danger or am I just reacting from the past? Address unhelpful cognitions about the trauma themselves and the world. Reduce chronic stress to help the HPA access, rebalance, and recover and assist the person in integrating the trauma narrative. So it's not a loose end that's just kind of sitting there in their amygdala. They've made some sort of sense. 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